Managing capacity of itensive care units

Managing “patient flow” is one of the most challenging aspects of running any health care facility. Whether in a hospital or a clinic, there is a limited supply of resources but a seemingly unlimited supply of patients at least some of whom need care desperately. Managing capacity is then a critical issue. No where is the need for the careful management of resource more important than the intensive care unit. ICUs are set up to treat the most critically ill patients and it is here where the US health system can spend big bucks real fast.

One hospital that does very well managing its ICU is Montefiore Medical Center in the Bronx. The Wall Street Journal had an intriguing profile of just what they do (Critical (Re)thinking, Mar 26).

[H]andling the flow of patients in and out of the hospital’s 78 adult medical and surgical ICU beds, and anticipating who else might need such high-level care on any given day, requires precision management. Many hospitals struggle to do it effectively, but Montefiore doesn’t—thanks to several innovations spearheaded by Vladimir Kvetan, director of critical-care medicine, over the past decade.

Among them: Teams of critical-care specialists are dispatched to the bedsides of potentially critical patients before they are brought to the ICU to determine what kind of care they really need and where in the hospital that can best be provided. An “ICU Without Walls” system can provide ICU-level care anywhere if a bed isn’t immediately available. Terminally ill patients are offered palliative care instead of high-cost, high-tech interventions. And all of Montefiore’s ICUs—for medical, surgical, neurosurgical and cardiothoracic patients—report to the critical-care department, not individual medical services, facilitating patient flow and minimizing turf wars.

Such changes in critical care have helped Montefiore reduce its overall mortality rate from 3.5% in 1997 to 1.8% in 2009. In its medical and surgical ICUs, the mortality rate fell from 36% in the 1980s to less than 8% in 2004—in part because many terminally ill patients are now offered palliative care elsewhere.

Such aggressive management of the ICU has payoffs that reach beyond the units wards. Because beds are available in the ICU, for example, surgeries can happen on schedule and OR are not left idle. Similarly, the ER does not back up with people unable to move into hospital beds. At Montefiore, the emergency department has seen demand go up by 45% (according to the article) without overwhelming the ICU.

So what’s the secret sauce? It seems largely to be what my queuing theory friends call admission control. In plain English, that means not letting people in.

Dr. Kvetan, who joined Montefiore in 1983 and became head of critical care in 1999, began making changes about 10 years ago when he realized that many patients in the ICU didn’t really need such intense care. They needed faster and better evaluation before they got there. So he devised a system to provide that, while keeping more ICU beds available for patients who could benefit most from them.

Part of that involved converting Montefiore from an “open” system, in which physicians admit their own patients to the ICU and continue overseeing them, to a “closed” system, where critical-care specialists decide which patients are treated in the ICU and assume responsibility for their care. About one-third of ICUs in the U.S. operate on the closed system, and debates continue over which is best. Studies have found that some patients in closed systems miss the familiarity of their own physicians, but survival rates are higher because the specialists have more training in critical situations.

What backs up this closed system is a team at the hospital that travels to patients to determine whether they are appropriate candidates for the ICU. Thus instead of screening once patients get to the ICU, the call can be made while they are still in another part of the hospital using less expensive resources.

This is a nice example of how operational changes can greatly improve how a system performs. At one level the key change — better regulation of who gets access to expensive resources — is very simple. Actually implementing these changes and sticking to them, however, is likely challenging. First, you have to effectively take power away from some care givers. That has to be a difficult pill for some docs to swallow. Second, and perhaps even more challenging, is that you have to be willing to tell people that you are not going to do everything to save their loved one. That may be the rational and often the humane thing to do, it is not news that many people will accept easily.